This invention relates to an apparatus and method for documenting the findings of a physical examination.
The physician today confronts the following problems in his/her medical practice: the continually rising cost of overhead; the persistently shrinking patient base; the ever downward pressure on fees; the increasing risk of malpractice exposure; and the increasing need for better record keeping. Physicians must compensate for the increased cost of doing business by introducing practice efficiencies and by becoming more productive.
Traditionally, twenty minutes has been designated as the time required for a routine clinical encounter. However, because of economic pressures, many physicians are now expected to complete an encounter within nine to twelve minutes. To accomplish this without producing either patient dissatisfaction or error, the physician must have a method of both rapidly recording as well as rapidly retrieving patient information.
While economic pressures are reducing the time available for making a patient record, there is an ever increasing demand for better records. Accurate, complete, and easy-to read records become very important in a group practice where more than one physician may see a patient, and are required for a Medicare audit or an investigation of a malpractice claim.
In today's medical malpractice climate, it is especially important to keep accurate records. In many cases the courts have found that, "If the physician didn't document it, he didn't do it." The inability to document what was done is one of the most frequent reasons that malpractice suits are lost. Malpractice suits usually arise years after the encounter, and it is impossible to predict which encounter or problem may trigger a suit.
Some physicians choose to dictate a patient report during or after the examination. However, at an average transcription cost of about $2.30 per report, this is a costly procedure. Furthermore, if there is any ambiguity in the dictated message, often there is no other record to clarify the ambiguity.
Other physicians use pre-printed forms to save time and reduce error. A pre-printed form may take the physician through a standard exam in a logical order and allow normal findings to be checked off. However, it is difficult to use pre-printed forms for routine office visits because of the unpredictable nature of any encounter. Further, to use only pre printed forms would rapidly fill up a chart with separate pieces of paper. Filing space is usually at a premium, and fat records with little information waste valuable space.
Physicians may also purchase rolls of stick-on labels suitable for use on insurance and collection files, laboratory reports and samples, and on patient records. However, the scope to these labels is too limited to provide any measurable assistance in a routine office visit where a wide range of medical problems may be encountered.
It is an object of this invention to provide an apparatus and method for documenting the findings of a physical examination.
Another object is to provide a system for accurately and completely documenting a physical examination in less time and at a reduced cost.
Another object is to provide a system for accurately and completely documenting a physical examination without generating voluminous patient records.
Yet another object of the invention is to provide a system wherein anatomical drawings are provided to speed the description of abnormal/positive findings.
A further object of the invention is to provide a system wherein a permanent record of a matter discussed at the examination is made by the patient.
A further object of the invention is to provide a system for generating a patient report that is legible and easy to read.
A still further object of the invention is to provide a system for generating a patient report wherein information is recorded at predictable locations and thus rapidly retrieved.
Another object of the invention is to provide a system wherein normal/negative findings are rapidly and completely documented using a check-mark system.